Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Thursday, September 22, 2011

Early on in Shrink Rap life, I wrote a post called Transference to the Blog. A bit tongue-in-cheek but it was inspired by the idea that readers seemed to have their own feelings and internal relationships with Shrink Rap, just as we had with them --so Counter-transference emanating from the blog was also addressed. As was transference to the duck.

Over the years, the feelings and tone in the comment section of Shrink Rap has varied quite a bit. At times it's warm and fuzzy with people writing in to tell their own stories-- good and bad-- and readers offering one and other support. At other times, it's been rather hostile with reader writing in to express their venom toward psychiatry and to criticize other commenters who say they have benefited from treatment. From my perspective, I thought things had calmed down, at least a bit, but we've gotten several communications from readers complaining they feel attacked if they make comments. I worry that our continued commenter-constituent base of those who criticize the field has served to silence those who might like to have a voice. Even my co-bloggers seem to have lost interest in engaging in these conversations.

Some of the commenters have asked why people return to make the same points over and over. What interest is there in this drum beat of reiteration after reiteration of why psychiatry is bad. I've wondered the same thing, and wondered why they don't form their own blog! If you're a Republican, don't you frequent Republican blogs? Why hang out and hound the Democrats? Do Jewish people standout side Catholic Churches to make the point that the Catholics are wrong in their beliefs? Which brings me to the subject of Transference to the Blog. Obviously, I can't speak to the motivations of people I don't know, but I am allowed to speculate in my head, and I can't help but assume that those who visit with a repeated agenda that opposes the spirit of by-psychiatrists-for-psychiatrists (and anyone else who might enjoy the ride), do so because they've had a bad experience and Shrink Rap might serve the purpose of being a flame to the metaphorical moth. It feels like a compulsion to revisit the site of a trauma in the hopes of mastering it. Sorry if this is too shrinky for you, but oh, hey, I'm a psychiatrist and we do sometimes think this way.

When people make the same adversarial comments over and over, it gets old and it stifles new ideas and new discussions.

If you believe that psychiatrists wrong patients by inflicting diagnoses on them, that it's wrong to take medications for psychiatric problems or psychic distress, that psychiatrists have evil motives, that psychiatric disorders do not exist, that psychiatric hospitals inflict damage, that involuntary hospitalization is never, ever, warranted no matter how sick or how dangerous someone is, or that psychiatry is about inflicting punishment/being coercive & controlling, and not about healing or treatment, then please know we have heard you. You're welcome to your views, but the writers of Shrink Rap don't agree that these are over-riding themes in psychiatry as a whole, and expressing the same opinion and rationale for the 27th time is not going to change this. On the other hand, it does appear to offend many people who might like the opportunity to comment, express themselves without a barrage of insults, and garner either support or similar stories in a welcoming environment.

This may be read as Don't Criticize Psychiatry. Read it as you wish. I don't think we've ever steered readers away from an honest look at the issues, or that we defend every aspect of our work as done by all of our colleagues. Our book is about psychiatry with the good and the bad, and we mostly discuss it in positive terms with the hope that this will set the standard : Hey, none of the docs in Shrink Rap are prescribing medications after 10 minute evaluations, they all listen to their patients and have thoughtful discussions-- maybe that's what I should expect.

If you've made your point, it's been made. If you have a new point and it critiques psychiatry in a new way, please say it in a manner that is respectful of those who may be struggling.

71
comments:

"It feels like a compulsion to revisit the site of a trauma in the hopes of mastering it." I think this sounds like a promising analysis. I doubt the people who are extremely adamant have been able to express to their displeasure to the MH Professionals they actually worked with or work with, so they are choosing a more neutral and less intimidating setting. Unfortunately, if this is the case, they will continue this pattern until they resolve the conflict created for them from their actual experiences. The likelihood of them actually confronting the appropriate parties, however, is slim, because I would also imagine its a lot easier to ream you and other psychiatrists who can't yell back. There are all sorts of frightening possible responses if they confronted their actually "attackers," but if they confront you, they can be reasonably sure of your mode and method of response.

It is too bad some of your commentors have experienced a sense of persecution from other commentors. Posting on the internet, while somewhat anonymous, can be nerve-wracking because it can open up a person to a barrage of emotional abuse. It sort of amplifies the "bully/victim" pattern of childhood and adolescence. I know that concern about this has caused me to be hesitant with what opinions I express and where I express them. Hurtful words hurt, whether they are from someone I know or a random stranger on the net.

Regardless, I have been reading your blog for several months now, and despite the negativity of some of the posters, I have found it insightful, edifying, and thought-provoking. In a profession which so many accuse of being smoke and mirrors, its nice to see the kind of genuine self-disclosure which Rogers and so many others in our field found be the cornerstone of their work. If things in my life ever got to where I needed to consult a psychiatrist, I would hope to go to one like you guys.

There are several reasons that Jewish people do not stand outside Catholic churches telling Catholics they are wrong in their beliefs.1.Jews do not actively seek converts so there is little to gain in telling anyone else they are wrong in their beliefs.2. Jews believe that the righteous of any faith will get to "heaven" so there it is not about what one person believes but rather about how people are in the world.3. For those Jews who spend Saturday in synagogue and Mon-Fri working, when else are they going to get their errands done but on Sunday. There is very little time on a Sunday to go bother someone about their beliefs. 4. Most jews take the attitude of believe whatever you like so long as you grant me the right to believe what I like. 5. These days a great many Jews would be pissing off the in laws if they did that.

Battle Weary: :~) Carolyn: Thank you!Rob: We really didn't moderate out more then a couple of posts and I like the whole concept of allowing different view points. We have learned a tremendous amount from our readers, and I think there's some stimulation to the arguments. My only objections are to the concept of repetitive missionary-style haranguing and to anything that's done in a way that is disrespectful. Mostly, we have intelligent, insightful, articulate readers and I'm happy to hear opposing views, once, twice, even three times, but that's enough. It was hard to figure out what to moderate out.rbh: thank you for the support. I said it once a few months back in the comment section when things had gotten really ugly.Anon: well said. CatLover: take a picture of the ducks? They do make good cat toys.Rob: Clink really enjoys your word analyses.

"It feels like a compulsion to revisit the site of a trauma in the hopes of mastering it."

I think there could be accuracy in this but there is one other component that you aren't (imo) taking into account: that patients who had bad/wrong/unethical experiences want to prevent the same thing from happening again. On occasion, when I read your blog, I see hints of something that makes me recall experiences I've had - good and bad. I think you guys are overall good psychiatrists and sometimes I think that there may be something you're missing or not thinking of, and to that end, I feel that sharing my disagreement could be beneficial to you -- to perhaps see another perspective. Sometimes you edge towards the same view more then once; I may express the same view each time, as pertains to the individual post. I happen to think my opinion is not polarized or unfair (I don't think hospitalization should always be opposed and I don't hate all medication. I also think hospitalization is often a forum for terrible abuses and not beneficial, and I think medication isn't always appropriately (or effectively) used) and that's valid.

Granted, I ralize you're talking about vicious or unrelated comments, but there is some middle ground. I may feel like I've "mastered" specific bad psychiatric experiences (with professional help, granted ;) ) - but that doesn't mean I don't think you as a psychiatrist won't benefit from hearing another perspective.

Though I am not a psychiatrist (and this is a blog by psychiatrists and for psychiatrists), I think I still enjoy the ride enough to comment.

Maybe you should feel a little bit flattered that these people keep coming back to bash psychiatry. Because that must mean they find the field of psychiatry awfully important! It seems to matter a lot to them.

I honestly think that the only way that psychiatry is abusive is when the psychiatrists just aren't that good (and there are a lot of bad doctors out there). Maybe what I am saying is that correlation does not equal causation (Dr. So and So is a psychiatrist. He over medicates and hospitalizes people for reasons that don't make sense. It must be because he's a psychiatrist!). Are there corrupt psychiatrists because psychiatry is corrupt, or is psychiatry corrupt because of the psychiatrists?

I had psychiatry problems too. When I was a kid I was learning disabled. I still am. I was tested at school when I was a kid for an LD, cuz I struggled so much. I had big discrepancies in IQ, but the school told my Dad they thought I scored that way because my Mom died and I was emotionally disturbed. They then told him he would be neglectful if he did not get me help. That led to spending the majority of my public school years on a variety of psych meds that either made me feel worse or did not help. I failed out of high school. I then stopped all the meds, went to community college, was tested for an LD, was told I qualified as an LD student and could be accomodated, and ended up receiving a BA from a university...

And you know what's nuts, that was all from telling an academic counselor at college about my learning problems. She then said I should be tested cuz it sounded like an LD. I saw like 3 different psychiatrists growing up. None of them ever suspected I might have been LD??? LD is even in the DSM. And I don't know if that's just the negligence of psychiatrists or if it's the field of psychiatry that has poor diagnostic criteria that should be revised...

I don't see anyone attacking, I see people expressing differences of opinion. Although, I have seen attacks in the past. I guess we all have different levels of sensitivity to things, though. It's the differences of opinion that make it interesting.

It's what I loved about Furious Seasons - you would get the haters who thought meds were always bad, the ones who thought meds were always the answer, psychiatrists and patients and everyone in between. It was pretty lively at times. But, fun and interesting.

Jenn, I saw your comment, even if blogger ate it (they seem to show up here hours later). Happy to have you at Shrink Rap.

Anon who doesn't see anyone attacking-- clearly people feel offended, if you don't see it, it's possible that you are intentionally part of the problem.

In general, I think any "I had this bad experience" is fine. It's the generalizations and judgements that are the problem.

Anon with the LD: adult psychiatrist are not trained to recognize learning disabilities. I don't if child psychiatrists are. It may be more the realm of the educational system and neuropsychology then of psychiatry. That doesn't mean it shouldn't be.

Last anon: I don't stink, I shrink. And all three of us are able to ride a bicycle, though Clink has been known to become airborne in the process.

I'll confess to being one who no longer wanted to comment due to feeling jumped all over. There have been a few posts where I'd be willing to share personal experiences, but no thanks under the current environment. Call me oversensitive if you will, but I'm being honest - and perception does matter... I tend to look at most things in life extremely objectively - or at least, if opinionated a certain way, with an open mind willing to engage in other thoughts and ideas. But the close minded flat out slam downs make it difficult to have any sort of conversation that I would consider engaging. I find it demoralizing...especially when I have seen psychiatry help so many, young and old. I'm not discounting the bad stories - but perhaps some of you need a reminder about the good ones. Some of us probably wouldn't still be here or be doing what we're doing if it wasn't for the help of some great psychiatrists at different points in our lives. No shame in that! That is all. :)

Dinah, I totally agree with what you wrote. I tend to respond best to the posts that are thoughtful and not dogmatic. It is exciting to read alternative ideas that are posted in a respectful manner, but equally so the posts that are repetitive and negative stifle the best kind of dialogue.

I was going to write a Rant on exactly this subject, but you said it better and more carefully than I would have been capable of doing.

Hope a number of posters come to Peabody on Sunday. Will you be selling Shrink Rap sweatshirts with ducks emblazoned thereon?

Thanks for writing this Dinah. It reads to me that you are a bit weary, and I apologize to one and all if I contributed to stifling discussion in any way. My skin stays beautiful due to the perpetual egg on my face. ;}

I learn a lot from your posts and from commenters. However, the single minded one subject commenters are a puzzle. I wonder if they are nursing hurts, and I'm not sure how to help.

I've been playing with the idea of hospitalization as traumatic, and I'd like to throw out the idea that iatrogenic traumatization isn't exclusive to patients with psychiatric hospitalizations. More than half of all patients who spend time in critical care units are diagnosed with PTSD within 12 months, if I recall my stats on this accurately (I'll go nose around the literature to verify and will correct this if I'm mistaken). Many patients are harmed by various aspects of the hospital environment: noise, alarms, deliberately interrupted sleep, infectious agent exposure, physical violence, humiliation, powerlessness - and the list goes on.

I don't know if this is the blog for the topic, but if you find it of interest, I'd welcome the discussion about how to transform inpatient environments and experiences from trauma inducing to therapeutic for different patient populations.

I formerly had a professional interest in hospital based nursing delivery processes/patient outcomes, and I've been traumatized by my recent patient experiences in hospitals, so I'm not coming at this from a particularly objective stance.

I recently read a line in a book that said something like, "The sure, repetitive mind is a closed mind."

Perhaps too black and white, but as a more moderate view (it was phrased better in the book, to not sounds so blac,k and white, to not sound so "sure" itself.) I found myself thinking of someone specific when I read this.

On another note, aek, I can certainly see that; I mean, how helpful is it for a knee replacement patient to not get any sleep for two nights straight because of the thingies that are constantly inflating/deflating against your feet? I did the best I could to tell my mind I was skipping along a path of mushrooms or marshmellows, to help my weary mind and body drift into a dream that would fit the sensations, but no such luck. No sleep may not sound traumatizing but after everything else involved, it wasn't good.

Not on the level of waking up during your own surgery, though, and hearing the power tools being used on and in you.

aek, yesterday in the NYTimes was an article telling that Carolyn Buchsbaum and her husband gave 42 million dollars to the University of Chicago to fund an institute to study how bedside manner of physicians can be improved. She herself had a bad experience with an insensitive physician, and most of us know people who were so traumatized.

People who are hurt, sick, or injured are particularly vulnerable, and insensitivities that are not even noticed by the perpetrator can have lasting negative impact.

How right you are about the "regular" hospital experience. I've spent a lot of time in hospitals and otherwise undergoing medical procedures, and I have a lot of really horrifying memories. Many of these memories are what led me to nursing in the first place. It's a day in day out thing that I incorporate the power of these memories into my care as a nurse. If what I went through can help me help more people by providing very detail oriented and compassionate care, then I'll consider it worth it, in some odd way. Without the meaning of that, it doesn't feel so great...

I'm a terrible IV stick, and I was on the step down ward from the cardiac ICU when all of my veins were shot. The nurses weren't able to get any more IVs, and I'd had a PICC placed, but it went up the IJ instead of along the subclavian and thus could not be used. After 24 hours of no medications, I was feeling fairly crappy. The resident came in, told me that I wasn't a priority patient for a central line (Don't ever say that - even if it's true), and told me she was certain she could get an IV in my foot. Now, I could care less about IV sticks the majority of the time - they don't bother me anymore as I've had hundreds. But her sticking my foot hurt like HELL - and after about 5-10 minutes of her poking around, I finally said "OW!" She never was able to get it - famous last words, stating you can get an IV with such certainty...

Only one of how many experiences that come to mind when I think of some of the more insensitive moments.

Obviously, I can't relate to my NICU patients, but I can relate to some of the hospital experiences of chronic and acute illness that their parents are going through. I will try to ease that emotional burden to the best of my ability every day. Doesn't always work, but it's certainly worth the effort!

Thanks for your responses, sarebear, jesse and carrie. I'm sorry that you suffered pain, sleep disruption and other indignities. Jesse, I read that NYT article and am pleased that a more rigorous effort is being funded to develop and sustain better physician and patient relationships.

Maybe we could explore some ways to fundamentally improve patient experiences. As one example, I learned that there are no established standards of nursing practice and care for patients being treated on non-psychiatric units who have comorbid psychiatric or primary psychiatric problems. Usually those patients are experiencing varying degrees of crisis, and yet, at most, they are assigned intrusive one:one observation by an unskilled, uncommunicative worker. They receive no crisis intervention nor any therapeutic communication or support while they "wait out" being "medically cleared".

On the other hand, on psychiatric units, patients are denied the presence of family. There is no such thing as rooming in or unlimited visiting hours. Patients are told generically to "go to groups". However, there is no evidence that "groups" affect patient outcomes. The traditional ward structure which uses earned privileges also has no basis in evidence-based practice. In no setting except psychiatry are patients coerced into socializing with other patients and being referred to as peers. There isn't a post partum peer group or an oncology peer group or any other pathology based patient peer group. This was done, in my view, for ward administration ease and control of inmates. Prisoners and pupils are directed to eat and socialize together as peers, but no other group of adults is directed to do this under the guise of a therapeutic milieu.

What about advancing the idea of making all inpatient nursing units open to unlimited visiting by the patient designated significant other or healthcare proxy? Patients need readily present advocates, and this would be one way to help achieve this.

As to sleep, we could "go back to the future" and do an automatic hall and room light dimming at 10 pm along with cork floors/walls and closed patient doors (with windows/built in privacy blinds). I always used a flashlight during night rounds to assess patients, and there is no need to flip on overhead lights.

I am totally confused. If you had written this blog entry 2 months ago, it would have made total sense.

But as you said, you felt things had calmed down. So I am not sure why people feel attacked if they make comments.

And please don't tell me I am being insensitive. There have been many things I wanted to say but held off out of fear it would come across as too controversial.

I guess the question is what constitutes an attack. Certain ones are obvious.

But let's say you post a blog entry on the Star D study. And I comment that on the boringoldman blog, the owner has referred to it as a fraud. Is that an attack?

For people not familiar with this blog, it is run by a retired psychiatrist who is not anti meds.

I also think if you post a controversial topic like the one on Howard Dully, you're going to get a heated discussion. So if people say something that may be perceived as an attack on psychiatry, I am not sure why you are surprised in light of the topic.

Now if someone essentially said, "psychiatry stinks" under your blog entry, Come meet the Shrink Rappers, I would agree you have every right to be angry.

You also seem to be making this an issue of pro psychiatry vs. antipsychiatry. But when people complained about abuses in mental hospitals, it wasn't the antipsychiatry folks who were squawking the loudest.

Regarding visiting blogs like Shrink Rap and not places that differ from my political views, that is a great question.

I have thought of going into advocacy work regarding the issues that have come up on this board and this is great practice for me in dealing with opposing views. Not sure that will ever happen but even if it doesn't, l have still learned alot. Learning how to disagree with people respectfully is always useful in my opinion.

By the way, you seem to think that everyone who is anti psychiatry wants to come to this blog and give the shrink rappers h-ll. People who don't like psychiatry whom I told about this blog have said they have a very negative impression and will never comment on it.

Finally, to Caroline Cummings - Be careful about assuming things about people. As an FYI, I did tell my former psychiatrist that I wished I had never seen one. I cushioned it by stating that I accepted my share of responsibility.

His response was to ask questions that acted like I was relapsing. Great way to facilitate discussion. Yes, I am being very sarcastic.

Oh and I have definitely not relapsed even though I have been med free for over a year.

Finally, I have worked in places that greatly differed from my political views and it was quite an experience. I temped at one organization where my tongue got very sore:)

One time, I made a mental note to watch my facial expression regarding a specific controversial issue. So I start talking to a co-worker about a very neutral subject. This person somehow turns the subject back to the issue.

Oh bleep thinks me, now what the heck do I say. I recall stammering but somehow I said the right thing. Phew:)

Dinah, thank you for this post. I have also thought that the repeat anti-psychiatry posters are attempting to master something, particularly because many of them will not engage in a back and forth dialogue. I don't know if I have said this before, but I continue to be amazed and impressed with the openness of Shrink Rap to not duck and cover (no offense to ducks intended) when it comes to inviting potential criticism of psychiatry or the history thereof--the lobotomobile post, for example. Not all medical specialties or blogs, etc. are like this.

aekThe thing is that illness of all kinds: chronic, degenerative, traumatic, surgical treatment involving ICU step-downs to medical-surgical units and psychiatric in-patient stays are traumatic in varying ways by DSM criteria. In each circumstance the person is experiencing physical and mental pain with feelings of helplessness and thoughts that they might die now or thoughts that they will someday die (in a new, fresh way). That is the reality of serious illness. (My mother is a nurse so I am smart and know that nursing literature is replete with studies of ways to decrease the traumatization that goes on from ways to change the lighting and sound in ICUs to stop ICU psychosis to ways to talk to and touch patients before the nurse anesthetist administers anesthesia to systems approaches to prevent the need for chemical or physical restraints in the psych ER.) Your ideas about making changes to psychiatric care on units is interesting, however, insurance reimbursement to hospitals and length of stay they will pay for has shortened so much that in the last 10 years that 2/3rds of the psychiatric units in my area have closed. Anything that would require more staff to monitor family members and their interactions with patients, etc. would not be entertained by hoospital adminstrators at this time.

aek: The challenge with letting family and friends on to the inpatient psych unit is that sometimes patients are there, in part, because of those unhealthy relationships. Also, psych units unfortunately have become the default place for drug and alcohol detox. The more people on the unit, the greater the chance that contraband will get smuggled in. Maybe this isn't as much of an issue for private hospitals, but it certainly was where I did my residency. It wasn't unusual to recover drugs and even weapons from people on admission.

Thanks for bringing up those well known and well worn caveats. However, I don't think they have to be full stop impediments to making profound changes. Contraband and unhealthy family relationships occur across all patient populations. They are addressed via different strategies, and they could be addressed via rules for visitation with a one strike, you're out policy. Moreover, you can turn the problem into a benefit by being able to observe the family dynamics more in depth, open patient education to families so that they can more fully support patients, and best of all - patient outcomes can be measured via readmission rates, care compliance and other established indicators.

Staff on non-psych units had the same general concerns, and they did not find that they spent more time chasing "bad family behavior".

I think it would be useful to look at cooperative care units (NYU had the original one way back when) for models of utility.

Bottom line is that few patients are willing to be hospitalized for psychiatric problems - even less when they have previously experienced an inpatient stay. That says that it isn't therapeutic. So, regardless of insurer hassles and staff convenience, we need to study what actually is therapeutic and of benefit to patients. Change is scary, but it is not the enemy. A little CBT here might do wonders (grin).

AA: I have your post in my email. If blogger doesn't get it up soon, I will post it for you. I do think it's concerning that a number of people have written in saying "thanks for this" and others have noted that they were troubled by the comments and you begin by saying you're not sure why people feel attacked.

aek: This was a post requesting that commenters not harp on the same themes over and over and it had nothing to do with inpatient hospitalizations, and you've managed to turn it in to a discussion of how hospitals are traumatizing. Case in point.

Anon who understood being deleted, I have not deleted any comments and I don't believe Clink did either (Roy is away). You were eaten by blogger. He is socializing with the other blogs and they sometimes eat each other's comments. Very annoying, but I suppose it's healthful for him.

Anonymous has left a new comment on your post "Transference to the Blog, Revisited":

Dinah,

I am totally confused. If you had written this blog entry 2 months ago, it would have made total sense.

But as you said, you felt things had calmed down. So I am not sure why people feel attacked if they make comments.

And please don't tell me I am being insensitive. There have been many things I wanted to say but held off out of fear it would come across as too controversial.

I guess the question is what constitutes an attack. Certain ones are obvious.

But let's say you post a blog entry on the Star D study. And I comment that on the boringoldman blog, the owner has referred to it as a fraud. Is that an attack?

For people not familiar with this blog, it is run by a retired psychiatrist who is not anti meds.

I also think if you post a controversial topic like the one on Howard Dully, you're going to get a heated discussion. So if people say something that may be perceived as an attack on psychiatry, I am not sure why you are surprised in light of the topic.

Now if someone essentially said, "psychiatry stinks" under your blog entry, Come meet the Shrink Rappers, I would agree you have every right to be angry.

You also seem to be making this an issue of pro psychiatry vs. antipsychiatry. But when people complained about abuses in mental hospitals, it wasn't the antipsychiatry folks who were squawking the loudest.

Regarding visiting blogs like Shrink Rap and not places that differ from my political views, that is a great question.

I have thought of going into advocacy work regarding the issues that have come up on this board and this is great practice for me in dealing with opposing views. Not sure that will ever happen but even if it doesn't, l have still learned alot. Learning how to disagree with people respectfully is always useful in my opinion.

By the way, you seem to think that everyone who is anti psychiatry wants to come to this blog and give the shrink rappers h-ll. People who don't like psychiatry whom I told about this blog have said they have a very negative impression and will never comment on it.

Finally, to Caroline Cummings - Be careful about assuming things about people. As an FYI, I did tell my former psychiatrist that I wished I had never seen one. I cushioned it by stating that I accepted my share of responsibility.

His response was to ask questions that acted like I was relapsing. Great way to facilitate discussion. Yes, I am being very sarcastic.

Oh and I have definitely not relapsed even though I have been med free for over a year.

Finally, I have worked in places that greatly differed from my political views and it was quite an experience. I temped at one organization where my tongue got very sore:)

One time, I made a mental note to watch my facial expression regarding a specific controversial issue. So I start talking to a co-worker about a very neutral subject. This person somehow turns the subject back to the issue.

Oh bleep thinks me, now what the heck do I say. I recall stammering but somehow I said the right thing. Phew:)

I have a bipolar disorder... I wouldn't wish it on anyone. At times it can be Hellish inspite of medication and psychotherapy... But thank heavens for the psychiatrist...they get it and understand it when no one else does. My psychiatrist and psychologist with their expertise, have helped me improve the quality of my life. I think the psychiatry bashing comes from 1.a bad experience from patients 2. lack of experience from those that fortunately have not had the need of a psychiatrist and have no first hand knowledge.

I asked about your interest in posting about making hospitalizations more therapeutic. Other commenters responded to that. I apologize for responding to them and pursuing it without first getting your approval.

Now that I know that I'm one of the commenters you find wearisome, I'll make this my last comment and visit and wish you well.

aep: "Wearisome" was never my word. It just wasn't the place for the conversation, but when I put up my comment, I also emailed the head of a local large psychiatric hospital and asked if he'd be interested in writing a guest blog post on what their patient satisfaction surveys show and what changes they've made in response to patient feedback. So you had me thinking, for better or for worse, and I haven't heard back. Let's see if we can find a better place to talk about patient satisfaction with inpatient stays. : ~ )

"I do think it's concerning that a number of people have written in saying "thanks for this" and others have noted that they were troubled by the comments and you begin by saying you're not sure why people feel attacked"

Dinah,

With all due respect, paraphrasing my first statement without posting the rest of my message (which I recognize is your choice as blog owner) is taking what I said out of context.

Like AEK, I feel like I am also one of your wearisome commentators so this will also be my last visit.

I wish everybody well and good health.

AA

PS - The Carlat blog, Thought Broadcast, and Family Dysfunction and Mental Health Blog allow dissenting views on their blogs.

AA: I thought I' d posted your entire post under my comment. Blogger ate it twice, and now I'm not sure I still have it (thought I'd posted it and then deleted it.). Looks like your last post didn't go either. Not deleted, eaten by blogger. I will go look in my trash and hope blogger doesn't eat me. It doesn't seem to discriminate

AA: here is your original post, posted by you> eaten by blogger. Reposted by me> eaten by blogger. Trying again:

nonymous has left a new comment on your post "Transference to the Blog, Revisited":

Anonymous has left a new comment on your post "Transference to the Blog, Revisited":

Dinah,

I am totally confused. If you had written this blog entry 2 months ago, it would have made total sense.

But as you said, you felt things had calmed down. So I am not sure why people feel attacked if they make comments.

And please don't tell me I am being insensitive. There have been many things I wanted to say but held off out of fear it would come across as too controversial.

I guess the question is what constitutes an attack. Certain ones are obvious.

But let's say you post a blog entry on the Star D study. And I comment that on the boringoldman blog, the owner has referred to it as a fraud. Is that an attack?

For people not familiar with this blog, it is run by a retired psychiatrist who is not anti meds.

I also think if you post a controversial topic like the one on Howard Dully, you're going to get a heated discussion. So if people say something that may be perceived as an attack on psychiatry, I am not sure why you are surprised in light of the topic.

Now if someone essentially said, "psychiatry stinks" under your blog entry, Come meet the Shrink Rappers, I would agree you have every right to be angry.

You also seem to be making this an issue of pro psychiatry vs. antipsychiatry. But when people complained about abuses in mental hospitals, it wasn't the antipsychiatry folks who were squawking the loudest.

Regarding visiting blogs like Shrink Rap and not places that differ from my political views, that is a great question.

I have thought of going into advocacy work regarding the issues that have come up on this board and this is great practice for me in dealing with opposing views. Not sure that will ever happen but even if it doesn't, l have still learned alot. Learning how to disagree with people respectfully is always useful in my opinion.

By the way, you seem to think that everyone who is anti psychiatry wants to come to this blog and give the shrink rappers h-ll. People who don't like psychiatry whom I told about this blog have said they have a very negative impression and will never comment on it.

Finally, to Caroline Cummings - Be careful about assuming things about people. As an FYI, I did tell my former psychiatrist that I wished I had never seen one. I cushioned it by stating that I accepted my share of responsibility.

His response was to ask questions that acted like I was relapsing. Great way to facilitate discussion. Yes, I am being very sarcastic.

Oh and I have definitely not relapsed even though I have been med free for over a year.

Finally, I have worked in places that greatly differed from my political views and it was quite an experience. I temped at one organization where my tongue got very sore:)

One time, I made a mental note to watch my facial expression regarding a specific controversial issue. So I start talking to a co-worker about a very neutral subject. This person somehow turns the subject back to the issue.

Oh bleep thinks me, now what the heck do I say. I recall stammering but somehow I said the right thing. Phew:)

Dinah,I agree that sometimes there is transference to the blog.I also think this differs from anti psych types who come with their own agenda. I would like to comment on your comment about patient satisfaction surveys. As someone who has been a patient and never knows when or of they will be again, i have never complained to the person responsible for receiving patient complaints even when my human rights have been violated, as confirmed by doc. Why not? Unlikely that any change will result and won't I be royally sc***ed over if I land back in that ward? Just saying.

ShrinkRap poses only two extremes. There is on the one hand "venom" from people who believe that psychiatry is all bad and evil, and there is everyone else. Where is the acknowledgement of the middle ground? That some people benefit, some do not, and, yes, some suffer harm? That the profession could use some overall improvement in its standards of care, its science, its ethics? I took a psychiatric drug advertised as safe and effective, and it was ineffective and toxic: the tinnitus began almost immediately and is nonstop. That was seven years ago. The psychiatrist who prescribed it responded by immediately terminating the doctor-patient relationship. I never heard from him again, and no psychiatrist I have seen is even able to address the issue. Please, leave room for a middle ground. Not all criticism is venom.

Comments have been civil and restrained on Shrink Rap lately, so the timing of this post is very odd and feels like an attack on patient posters to me. I had comments on the "Is This Depression?" post, but refrained from posting due to several psychiatrists' complaints on that post that the percentage of psychiatrist posts was too low.

Perhaps you are deleting venomous posts that we are not seeing and that is affecting your perception of what is being posted. Perhaps the posters who are complaining about the patient postings are reacting to comments on KevinMD and elsewhere (I did not read the post on depression, but it was referenced), not here.

Many of the people who were posting offensive comments are already gone and certainly those that were the worst are gone. This post and the continued complaints about patient posters feels to me the same as what you are complaining of, that the issue is being harped on and repeated over again, even after the situation has passed. Why is this post up now?

Personally I don't see patient posts or criticism of psychiatry posts as the issue. I think it's when the people who are so critical of psychiatry jump on anyone that says they've seen positive things and repeatedly tell them how wrong they are, that they are blind, that they don't know what really goes on, and so on. To see that repeatedly makes one not want to comment at all. There is no right or wrong - people's experiences are what they are. Just because someone has seen something good go on does not mean they refuse to believe that bad goes on as well. I've heard and seen enough to KNOW bad goes on, and I still have concerns about things I hear regularly. BUT - I've also seen a lot of good. There is plenty of middle ground - I think it's those who are so extreme as to not allow any commenting one way or the other to go by without having to say something antagonistic about it is what felt threatening to me. I gave up completely on one topic and refrained from posting on many more because sometimes the reactions are hurtful when it is something quite personal.

To the anonymous who commented about not filling out surveys due to fears of repercussions - the surveys are completely anonymous unless you write an identifying comment that would be recognizable to staff.

Blogger ate my comment. Dinah - if you can re-post it at some point, that would be awesome.

And Sunny CA - as I said, I was one of those who felt that way - I don't read comments on KevinMD because of how they can get. And it was entirely from comments I read posted here that left no room for any disagreement that made me feel that I didn't want to comment at all.

Carrie,I know exactly what you mean. The smug evil out there can be appalling. I'd compare reading comments to turning over a rock, except that I think the teeming life revealed under rocks is cool whreas the venom revealed in many comment threads is just depressing. Question: how is the quality of Shink Rap comments now as compared to two months ago?

People posting bad experiences here, and the same conclusion drawn from them, over and over again: I do this. Or have done. I was ignored and I went away.

The bee in my bonnet is that psychotherapy is presented as side-effect free, when in my experience the power imbalance between provider and client is such that it can be extremely damaging. I drone on repetitively that complaining about problems with psychotherapy is much more difficult than complaining about side effects from medication. Dinah often observes that people obviously find it beneficial, otherwise they wouldn't keep coming back. In my experience, I went back because I was supposed to. I did what I was told, warned that it wasn't helping, and crashed horribly under professional oversight. Having proved - at the cost of a year of my life - that I was right that it wasn't helping, I was given permission to seek the help that I wanted - and that was very effective.

The only gatekeepers were cultural and personal expectations. I was free to stop psychotherapy at any time, but that would have proven to everyone that I wasn't actually serious about wanting to be better. (At least, I thought that.)

Sure, these expectations could theoretically have been different. But they weren't, and they kept me gritting my teeth and going back to see someone who wasn't helping. Meaning that there can be more than one reason someone keeps going back.

I've posted this over and over again with different flavours, hoping to get some uptake, understanding, acknowledgment of problems caused by power imbalances, and ideally an explanation of how a patient can take their power back, or at least a coherent model of how that's supposed to even work.

Eventually I got bored and stopped.

But in my case, that was why. The folks here seem reasonable, caring and very knowledgeable. They'd be the kind of people who could tell me that I wasn't wrong, or that the reason I'd run into trouble was Cognitive Error A which psychotherapists are supposed to be on the alert for and respond to with Supportive Response B. Or whatever. Put it into context.

What I *really* wanted was to get the idea out there, into the cultural mix, that psychotherapy isn't side-effect-free. Obviously Shrink Rap could never do that for me.

Anyway. These are some of the reasons for one-note commenting. Wanting to be heard pretty much sums it up, which is different from wanting to make a point.

Posted for Carrie:Carrie has left a new comment on your post "Transference to the Blog, Revisited":

Personally I don't see patient posts or criticism of psychiatry posts as the issue. I think it's when the people who are so critical of psychiatry jump on anyone that says they've seen positive things and repeatedly tell them how wrong they are, that they are blind, that they don't know what really goes on, and so on. To see that repeatedly makes one not want to comment at all. There is no right or wrong - people's experiences are what they are. Just because someone has seen something good go on does not mean they refuse to believe that bad goes on as well. I've heard and seen enough to KNOW bad goes on, and I still have concerns about things I hear regularly. BUT - I've also seen a lot of good. There is plenty of middle ground - I think it's those who are so extreme as to not allow any commenting one way or the other to go by without having to say something antagonistic about it is what felt threatening to me. I gave up completely on one topic and refrained from posting on many more because sometimes the reactions are hurtful when it is something quite personal.

To the anonymous who commented about not filling out surveys due to fears of repercussions - the surveys are completely anonymous unless you write an identifying comment that would be recognizable to staff.

Also, I've really been enjoying the discussion of hospitalization. I subscribe to comments in Google Reader, so I don't see them associated with a particular thread, so I don't even notice if they drift off-topic.

I thought Rob's comment that the hospitalzation of children against their will violates their rights to be extremely revealing. Childhood *is* a state of being confined against one's will. Except when it's living on the street.

--hopefully you did not lose an entire year of your life, just the the time and expense involved with psychotherapy and the time you spent thinking about it, but I hope some other experiences distracted you during that time. Our book has a section on psychotherapy gone wrong in a number of ways. It's one of Clink's "things"

To the poster who won't complain: http://psychiatrist-blog.blogspot.com/2011/06/please-complain.html

To those who feel that my request to end repetitive off-the-topic comments and to be kind to other commenters (and the bloggers!) is somehow the same as saying that Shrink Rap doesn't want to hear from you and doesn't allow opposing views, I am at a loss.

Blogger is eating comments. It ate a couple of mine (I"m copying this one first). I think Rob posted a comment, it got eaten, he reposted it, and so I thought blogger was delaying comments, but now I'm sure it's eating them. They show up in our email, even if they get eaten. We have not deleted any comments in a long time.

Yes, that was a beautiful example of me going on and on in the comments, over and over again on the same theme. (Rereading it today I'm rather impressed with my brilliance.) In that example I was explaining why I prefer psychiatrists to non-psychiatrist therapists. Psychiatrists (like you) think you're supposed to get better. If medication doesn't help you get better, a psychiatrist doesn't tell you there's value in medication itself and you should take it even if it doesn't help. Non-phychiatrist psychotherapists (like some I have worked with) tend to think that psychotherapy can be good even if it doesn't appear to be helping you, because even if your life is collapsing it might be helping you develop insight.

I've recently seen another model for this discrepancy in defining outcomes in midwives vs obstetricians. Obstetricians want a healthy baby and a healthy mother. Good care is defined by its ability to increase the liklihood of these particular outcomes.

Midwives may think a particular experience of childbirth - for instance, at home, without interventions - can still be valuable even if the baby dies.

I've only found out about this debate recently, but it's fascinating to me because of the parallels I've seen in mental health care.

(This is a debate in a corner of a particular kind of midwifery movement. I am NOT saying that no midwives are professional or that none of them care about babies.)

Why do I keep coming back here? Lots of reasons. I'll try to enumerate them.

1) Psychiatry has some real problems regarding Intersex and Trans people. One egregious example, if you're not a follower of "Dancing with the Stars" (I'm not) was Dr Ablow's warning on Fox that just seeing a successful Trans person would harm children and even cause them to be Trans themselves.

Unfortunately, he's not alone, and not part of an insignificant minority. I have difficulty dealing with such bizarre beliefs. This goes beyond differences of medical opinion into the realm of superstition and voodoo.

I won't ask you to make any comments on a fellow professional - he's just resigned from the APA, and there's been some complaints about his violation of the MAss. Psych. Assoc ethics code, so it would be inappropriate. Just to let you know that "Houston, we've had a problem."

2) For better or worse, I have to counsel some Trans and IS people in crisis. Many have co-morbidities. By reading the articles, and the comments on them by psych patients, it might give me some insight.

3) I also have to deal with various people who have severe issues with IS and TS people. Some are, I think, dangerously deranged. Most just mouth off, and are harmless, but some I think might be a genuine threat. I'll post more on that later. Anyway, again, any insight I can gain is useful.

4) While I don't match the diagnostic criteria for Social Anxiety Disorder, I get the feeling that my aversion to all social gatherings - parties, eating out, going to the theatre - may be sub-clinical, and redices my quality of life. It's better than it was, but still well outside the norm. Again, gaining insight by listening to others might help.

5) I enjoy your blog for its own sake. It's written with wit, and stimulates the intellect. Somehow you make the art of healing, often dealing with tragedy.... fun? Interesting anyway, and your compassion is obvious.

Example of the background noise that every IS and TS person is bombarded with pretty much every day - I class these as "harmless", though the unrelenting stream of them may be doing damage. Anyway, here's some comments on Australia's decision to allow Intersex people not to be forced to identify as either M or F if they don't feel either is appropriate for them:

---God that just makes me sick. A very small amount of people in the world are actually born with this problem then there's way more people who just THINK they're not the right gender. Well guess what, if you were born a girl or a guy THAT'S WHAT YOU ARE stop trying to change yourself. Leave the doctors open to the people who actually need the help.

I do love how people try to explain trannies away using "psychology" as a crutch when genetic science already has a way to determine your gender. Sewing on or inverting an appendage makes you another gender as much as stitching in whiskers and sewing on a tail makes you feline. Or if you'd prefer I use a psychological backdrop... Believing you are another gender does not make you that gender anymore than believing you are Napoleon makes you a late 18th century French military strategist emperor. If psychologists played into any other delusion as much as they did with "gender identity" they'd rightfully lose their license to practice.

You geneticly inferior filth.

Male, Female, Sodomist, this covers everybody

They should only have three options on any passport in the world: "Male" for human beings born male and currently male, "Female" for human beings born female and currently female, and "Freak" as a catch-all for pretty much everyone else who does not fall into the first two categories. This approach has the value of being the most accurate representation possible.

Every cell in you body has DNA which dictates whether you are male or female. External appearance or mood or DENIAL does not. You can complain about how you are a "Woman in a man's body", and even mutilate yourself with surgery and get implants and pump yourself up with hormones, for what? To look like some sad caricature abomination of a woman. Don't expect people to respect you as something that you can never be. It is like a white person who DEMANDS to be recognized as black, even to the point that they get nose surgery and wear black face all day. Should they be recognized as being a respectable black person, or some joke of a freak in denial?

toleranceis not a virtue, it is a cowardly vice , no one has to tolerate this homosexual maggot infested garbage

Why does the world continue to conform to the freaks and not the other way around

They've gone too far. If you want to be a freak, don't broadcast it to the rest of the world and expect us to accept it. These PC idiots are crying for "trans-species" rights now. As far as I'm concerned, if you don't feel like you are the gender or species you were born as --you're delusional and suffering from a mental disorder.

We wouldnt want to anger the freaks. They might genetically alter a hissy fit and call it a natural state of being!

there shouldnt be any thing on the passport other than ,,, m,,, or ,,, f,,,, all homosexuals, trannys, cross dressers, pedophiles, homosexual pedophiles, beast lovers, dead body part lovers, and sexual freaks should be branded on their foreheads with a big x

Transgender freaks should be shunned by society.

gays are defects in biology evil to god there is no other gender period aussies tend to be loons

JEWS and ZIONISM will destroy all cultures. We need the great father once again to take care of those SOBs

homosexual are the ignorant hating bigots they are complaing about, they cant stand themselves, live in shame and are the morally disgusting freaks that want to destroy your children by infecting them with perverted propaganda , protect your children at all cost

"A bunch of jewish professors who are bent on destroying western culture convinced a bunch of high school drop outs that "it's the right thing to do".

I bet JEWS pushed the issue, since their goal is to destroy western civilization. Read the zionist manifesto.

tolerance, political correctness and sensitivity are not virtues they are cowardly vices,,, stand up for who you are and what you believe, being tolerant does not mean respecting rights, they are not the same thing, condemning people who accept and exercise homosexual behavior is an act of justice and morally mandatory ,,, flush the gay bowel movement down the toilet were it belongs

In the animal kingdom and the universe, there are only 2 sexes. Those liberal left wing influenced by the Jews just invented a third sex which does not exist.

Stop trying to rationalize your perversion of nature by pretending it is 'normal'. You are freaks. The only ones that don't think so are other freaks.

This is what happens when Jewish Harvard school influence the academics of another country. The world should boycott any liberal freakish jewish made unnatural notions of sexes

This is ridiculous!. Western societies are replacing common sense with politcal correctness. You're just man (XY) or woman (XX). Period.

---

About 60% of the comments on that story were of a similar ilk.

You'll find them in newspapers, in sermons, in books, online, on TV, it's not possible to get away from them, nor to say "oh, there's always a crackpot minority". Well, yes there are, but the sheer quantity goes well beyond that.

Two issues:

Is it me, or are these people only marginally sane?

And what kind of psychological effect could such a constant torrent of venom have on the recipients over the long term - say 5-10 years?

As I said, these are the harmless ones. The threats are those whose online writings read very much like those of Jared Lee Loughner, the person who shot Senator Giffords. There's hundreds, even thousands of the harmless ones - and less than a handful of those that are cause for concern. Not enough to worry about.

If you aren't able to see that losing a year of life (allison) is a possibility then there's the discrepancy right there between the folks who have experienced severe illness and your thoughts.You wrote: "hopefully you did not lose an entire year of your life, just the the time and expense involved with psychotherapy and the time you spent thinking about it, but I hope some other experiences distracted you during that time"

That you think that's what losing ayear of life means...well, there's the discrepancy, and that's why you aren't getting what people who've experienced the severe illness are trying to communicate. Losing a year of life -- absolutely. Been there, also under the care of a psychiatrist. I didn't get better and crashed hard under her care. When Allison says she lost a year, I know exactly what that means -- Only it was more then a year. Was I dead? No, but perhaps that would have been better. I am healthy, stable and in remission now (yes, on meds) but even with clarity of hindsight and the awareness that I did rebuild my life, I wonder if it would ahve been better to have simply died and not lived through those hellish life years. I was unable to work/study, sleep or eat normally, unable to engage in close or aquaintance-type relationships. I was unable to think or follow conversation, unable to read a newspaper or follow the plot of repeat sitcoms. Unable to support myself financially or take care of myself. My relationships deteriorated and some were destroyed. What I lost professionally will never be made up for during that lost time. I had to go on disability to (barely) make enough to cover rent and food. There were no distractions, Dinah. This was not being sad over a breakup or PTSD from childhood issues. This was severe mental illness to which I did indeed lose years of my life. It was not about "time and expense in psychotherapy" only. To be honest, those were the least important pieces of it all. I was severely, severely depressed. I was cognitively crippled. I lost multiple years of my life -- and the time it takes to rebuild it is even longer (though yes, there are some distractions by that point).

If you are equating severe depression with mild depression or existential angst, then you are quite simply very, very wrong. I hope you don't make that mistake if you find yourself with a patient as ill as I (or allison, I assume) was - or perhaps you simply don't see people with that degree of illness and thus the conclusions you've drawn. Though I doubt you meant it as such, but what a condescending - and not comprehending - response! Distractions???

Alison, I did not post that link to say Look, you've talked about this already. I posted it to say Look, we addressed You're Supposed to get Better. Since I'm a psychotherapist, and I wrote that post, I didn't mean to confine it to getting better from meds, but they do make an easier example.

I realize you want more discussion of the power differential, and in the past, when I've said that this (or many other things people have brought up over the years....) is not my experience of psychiatry and that I don't hear these problems from my patients, I've been told by commenters that my patients are too afraid of me to tell me, that they really are having problems with their medications/withdrawing from their medications that I don't see...etc. If the issues came from my patients, I'd listen, but they come, with impunity, from people who have never met me or my patients. Let me see what I can do for you. To Be Continued

Jen, You may be right and I may have completely misunderstood Alison. I read it as she had lost a year of her life being distressed by the issues that occurred in her psychotherapy relationship, not that she lost a year of her life to the torment of mental illness. My best guess is that your interpretation of her comments was more accurate and it was about getting lousy care which left her ill, not interpersonal distress.

Zoe: Thank you for the kind words about Shrink Rap. I cringed at Keith's interview, too....not as much as I cringed at the people who boo'd the gay soldier in Afghanistan at the Republican debates. Oy.

I think most people repeat themselves because they don't feel they've been heard and repeat their behaviour because they hope things will be different (I suppose this is a bit like the mastery theory people have mentioned). Perhaps the problem isn't just that they say the same things, but that they hear the same things in reply?

As for how to respond when people post things that seem insensitive, aggressive, or hurtful, from a perspective of the Coordinated Management of Meaning (if you aren't familiar with it I'd invite you to learn about it) the message of any communication is made between people, and thus how you respond is part of that - a rather benign example, if someone says to me, "Nice dress" I might not know if they are admiring or mocking my taste, but if I reply, "Thanks! It is so comfy, I love it" I have made it admiring, regardless of the original speaker's intent. So a message can be seen many ways, e.g., hurtful or hurt; If you respond as if they are being intentionally hurtful you create something, and if you respond as if they are hurt you create something else. And not responding is also a communication. I read something in the excellent book How To Be Sick which went something like, "If the letter is returned, the message is never received" (of course returning letters unopened is pretty difficult!).

It is good to be reminded that things don't always go well, even with the best of intentions - mistakes aren't always attributable to incompetence. A lot of good has come out of anti-psych (-iatry,-ology, -otherapy) feelings, and poor personal experiences of mental health services, Michael White's narrative therapy for example, or Marsha Linehan's, DBT, were developed for just those reasons.

I lost a year of my life being good for a hospital-affiliated, PhD clinical psychologist who was actively interfering with my attempts to get psychiatric care.

For over a year, she watched me crash. And stay crashed.

When I eventually got on meds I observed to her that psychotherapy seemed even more pointless than usual. She suggested I stop taking meds.

My GP eventually gave me permission to stop seeing her. I was startled, because in my culture, giving up on psychotherapy and relying on meds for a fix instead is rejecting adulthood. I was desperately trying to be an adult. I'd never heard that psychotherapy might not be appropriate and that one could make an adult decision to quit.

Dinah, I understand that you addressed "you're supposed to get better." I thought it was really cute that there I was, perseverating away on that link. I also appreciate that psychiatrists appear to have more clarity wrt "getting better" than non-psychiatrist therapists do.

I think I'm alone among the complainers saying that if I had to choose between meds and therapy I'd choose meds, easily, hands-down, every time. I don't understand why psychotherapy gets such a pass. If meds have side effects, it's because psychiatrists are corrupted and pharmaceutical companies are evil. If psychotherapy has side effects, it's because the patient was doing it wrong.

I don't really need anything on the power differential, but if you're taking requests, perhaps a little on why a therapist might not refer a patient who is getting worse?

I'm with Allison on this. I've had good and bad therapists and good and bad psychiatrists over the course of 20 years and long since come to the conclusion that if i had to pick, I'd have to go with meds. No matter how good the therapist, if the medication is wrong, he is not going to be able to bridge that gap from sick to well. And if the therapist sucks but the meds are right, it's far more likely that the importance of his effect on my life will shrink.

To be honest, I'd say the same for side effects. As long as I can still stand, think and function, if the meds are working, then I will put up with those side effects, no matter how much they suck. And they do suck! But it's a trade off. And I say this with experience: I gained 75+ lbs on the first drug to truly work for me, and if I had to make the same choice over again, I would. I do not sleep, period, when on meds, unless using sleeping pills. My appetite is off, I have had a tremor for 15 years that will never go away, and yes, the sexual side effects. And if I had to go back and do it again, I'd make those same choices again...because I get to enjoy being alive and having relationships and meaningful work. I shouldn't have to pick between no side effects or no life but...it is what it is. I sometimes wonder if the people who are so anti-psychiatry just never found the right med/combination for them/their loved ones. To be clear, I don't advocate meds when not needed, or for mild depression that mightb e treated just as effectively with talk therapy. But for severe mental illness - yeah, if I had to make the choice between a therapist or meds, I'd go with meds in a heartbeat. And you know what else? I'm pretty sure that my excellent therapist would agree with that choice.

Jen & Allison, I'm curious how your comments relate to the posted topic Transference to the Blog? Are you saying that it is unreasonable for the Shrink Rap-pers to ask people to post "new" critiques rather than those that have been already made (such as issues of power and being incorrectly diagnosed or treated) perhaps because those issues haven't been sufficiently addressed? Is it that you want to remind them that each person's experience is different and therefore the criticism is different?

If the Shrink Rap-pers were to reply in a way that satisfied you, what might they say?

I get what Alison is saying about harmful, ineffective talk therapy. I actually had an experience like that. And I don't think it is a coincidence that the majority of the people I know who really benefited from therapy were people who paid out of pocket (because they wanted quality and someone who was highly recommended, cuz they didn't click with the ones covered by insurance.)

I did find out as I got older, that sometimes you really do have to hop around and check out different therapists. And that's not unusual at all. My sister went to an MFT who was really good, and I think this was the first one she went to. The therapist really helped her manage her anxiety. But I know other people who had to go through quite a few before they finally settled on someone.

I agree with Alison that therapists are not necessarily goal oriented people who strive for good results (I saw someone like that...and I actually wonder in hindsight why he never referred me to someone else who might have been more effective.) That was in my teen years.

As an adult, I am a lot more careful. I did consider therapy a while ago. I found a therapist covered by insurance, and then made an appointment. And that guy had issues. Strikingly, I noticed that when I said, as a therapist, he must have learned how to be manipulative, he told me yes he is and that he has to do that to get patients to see things his way. This was not the deal breaker (he had other issues), but that was exactly like something the therapist I had seen as a teen would have said. He bragged about being manipulative. I have no interest in seeing a therapist who wants to manipulate me and convert me to his point of view. I want one who is like the one my sister saw. Someone who can teach me how to manage my issues effectively, without mind games, and can produce good results. And that really should be what therapy is about for people like me or Alison: finding a therapist who can help us measure our strengths and our weaknesses, set goals, and work to attain those goals. It's about the patient, not whatever mind games the therapist feels a need to be playing. It's not indoctrination; it's a healing process.

There is a power differential...but only if you allow the therapist or whoever it is to have that power. If I think a therapist or a psychiatrist has control issues, I jump ship on that person.

To answer your question - I wasn't actively reading 2 months ago. I have followed this blog from the very beginning and used to actively comment under my old Blogger ID. I've deleted a lot of those comments over time because of the twists and turns of my life and the increased attention paid to blogging from people of all sorts. I also keep a much more private online life than I used to because of some issues that arose when I did blog and also what I saw happen to coworkers who led more open online lives.

So anyway - over the past few years I've gone in waves of how much I read - spent more time away than here honestly - but I did catch glimpse of some of the comments going on back then when I'd occasionally be reminded to check the blog from the twitter stream of Roy. :)

I'd agree that things aren't as ugly as they appeared then, but I also know that the openness we could and did display far earlier is no longer really possible without having to get yourself out of manmade webs of those trying to prove you are wrong.

WRT therapy - been going for a long time now. I started seeing my psychiatrist for therapy when he was a resident, and I've followed him through the various stages until now he's quite the attending - in geriatrics of all things, but he still sees me. :) The therapy was and continues to be very helpful, though we meet with less frequency now. The addition of a med a few years ago made a big difference. I asked to stop taking it and try something different several months ago - sometimes you can't see something is helping until you step away from it, I guess! I like that therapy has never required the knowledge of anyone else unless I choose to give it to them. It hasn't *always* been a positive experience - definitely several times where I felt majorly pissed - and not just because of any transference, either.

Honestly, if I had to choose between meds and therapy, I'd choose both. I don't think either one was nearly as effective without the other. I don't know if we'd call it major or not - but for 3 years, I didn't really leave my apartment unless going to work and never opened the curtains. My fiance started dating me towards the last year or so of that - he called my old apartment the cave. I like that my life isn't like that now. That's good enough for me. :) (Sorry for the length.)

Anonymous - sometimes comments streams take on a life of their own and lose relativity to the original post. Stream of posting, perhaps?

Carrie - I'm with you in that therapy and meds are not as effective without each other. But if I had to pick one, I think I'd have a better shot with meds and without therapy then the other way around.

Have been off APs for almost a year but the doc does not know. Take anti anxiety meds and accept the prescriptions for the AP that is meant to keep me sane. Never fill it. Doc has no clue. I like the doc but there is the power differential. Although we spent roughly equivalent number of years in school, I do not have an MD to append to my name. If I really feel I need it, and the day will come, I will resume the meds. Until then, it is not worth the argument with the doc. By this I mean to say to Dinah that it just may be the case that your patients don't feel they can be totally open with you. Does not mean you are a bad doc. Truth is that you some things you would rather not and patients know that. Not unlike having quasi grown kids. Don't ask, don't tell often works best. I sometimes wonder if I really would want to be a fly on the wall at kids' college. Answer is NO!!! Back to the main point, I believe I know what is best for me. I know what doc's opinion is but until doc has walked in my shoes I will decide and not get into a futile argument. It is not about childish rebellion. It is about an adult understanding that the only way to take charge of own life is to keep a lot to oneself.

Anonymous - sometimes comments streams take on a life of their own and lose relativity to the original post. Stream of posting, perhaps?

Perhaps, but then isn't part of the disappointment people are expressing is that many commenters are using this as if it were a forum. It is a blog, not a community. When the bloggers write a post they are inviting comments and thoughts on what they wrote about. I just wonder if that isn't another reason people repeat themselves, because they are posting in a context that isn't set up to give them what they want. I click to read the comments because I'm interested in peoples' thoughts related to the post. Of course I can scroll through various comments that aren't pertinent to the posted topic, but why should I have to?

To Anonymous who is concerned about stream of posting,In her response to Alison wrt to power differential, Dinah included these words: "I've been told by commenters that my patients are too afraid of me to tell me, that they really are having problems with their medications/withdrawing from their medications that I don't see...etc. If the issues came from my patients, I'd listen, but they come, with impunity, from people who have never met me or my patients." My comment was in response to that. Dinah's patients may tell it like it is. I have no idea what Dinah's patients think or do.I was simply stating how it is between my doctor and me, as a patient.

My husband, a jazz musician, had was discovered to have a benign tumor behind his drum over 2 years ago. We were referred to super-specialist by an experienced oto-laryngolyngist I had worked with at a multi-specialty group who had taken out my tonsils without killing me. My husband and I came in separate cars and despite all the research I had done into the various procedures I got out of my car and realized I had no real way of evaluating this guy who might be taking a bone saw to my husband's head. I realized that only by being calm and listening to him and to my husband would I have any hope of helping my husband make the right decision.Yes, there is a power differential in all medical interactions. I had had 2 babies: both times with pre-eclampsia---yes there is a power differential in medical interactions. The question is: how does the provider make you feel? Do they listen? Do they express understanding?This surgeon, we later figured out, had a mild case of Aspergers which made him work very hard, harder than I have ever seen a surgeon work, to understand my husband's feelings. He had a notepad of the inner ear in his office on which to draw different surgical options. (He, in fact, misinterpreted my anger and fear of him, the surgeon, for going to cut open my husband, as being anger at my husband for not being able to drive the children to school and fiercely defended my husband.) We fell in love with the doctor right then and there because he championed my husband--even if it was for the wrong reasons. And he continued to give my husband, who keloids (creates excessive scar tissue) the same kind of meticulous care. So, yes, there was a power differential. He was weirder--even than us--but he knew stuff we didn't know and didn't pretend to know. He saw my husband through 3 surgeries and restored his hearing and got rid of his tinnitus.After 3 and 1/2 years of twice a week psychoanalysis which I finally gave myself over to, I think it is OK if we do not understand the process all the time. I think the problem comes in psychotherapy, as it would in surgical post-operative care with an infection, if we had an infection and did not tell the surgeon (mind you I generally don't like surgeons). However, if you are working with a therapist and you are feeling a feeling you need tell therapist about the feeling and where you think it is coming from(if you know): even if it is the therapy. Otherwise, what is the point? This post has been about "transference to the blog" but has devolved into unspoken "transference to people's therapists" as per Allison, Jen, Jane and many others. If nothing else, a bad therapeutic relationship is a good opportunity to experiment with a safe environment to do something scary: renegotiate a relationship with a power figure (in person or it is not going to benefit you therapeutically) and if this does not work, to end that relationship in a safe way. For many women, in particular, this is something they have not seen modeled in intimate/up-close relationships. Therapy can be a learning space. I learned that I was the person with expectations blocking certain certain things in the relationships. (She was always going to be late, for example. That had nothing to do with me....) Other people need to fire their shrinks and this can be empowering to them. (I've done this.) But people playing games with prescriptions with their therapists or simply not being honest with their therapists have to accept that the therapy is not going to work and take their part of the responsibility.

@Sideways: My response was with Allison in mind, and I was really trying to bring her comfort. I didn't even think of that as a transference thing. Actually, I don't recall saying anything incredibly different from you. You wrote "The question is: how does the provider make you feel? Do they listen? Do they express understanding?" My post was about realizing that you won't click with every therapist (I certainly didn't), but there are some that can be a big help (such as with my sis and with other people I have met). Many have been through a few, but once they found the "right" therapist who knew how to help them things really started to look up. And that was all in my post.

And I don't have a crystal ball into Allison's mind, but I didn't read the power differential post in the same way as you. I thought what she was saying was that she was severely mentally ill (she "crashed" under this person's care). The person did not make her feel well, did not listen, and did not understand. But the therapist took advantage of her psychological distress and pinned the lack of results on her. Because she was insecure, she blamed herself and thought this was a sign that she was not being an "adult" and responding to therapy. When in reality, she is a very goal oriented person. She needed ways to measure success in therapy, and the therapist wasn't doing that. He was not identifying problems, evaluating strengths and weaknesses, and measuring her success based on improvements in her weaknesses (whatever those were). She could see measurable results from meds but not from therapy. Which makes me believe that he really was just giving a paycheck performance, because he could have just referred her to a therapist who was more goal oriented. And there are therapists who are like that. I thought the power differential was not that he knew more about therapy, but that he took advantage of her at a really distressing time by making her feel like it was her fault therapy was not working. Like a healthy person taking advantage of a handicapped person.

That's great that psychoanalysis has been working out for you. I don't think it would work for me! You're okay with not seeing the process, but that's not me! After having been in therapy, and talking to others who have gone through it, I have a better idea about what I think would be effective for me. I need things clear and direct. Like Allison, I need to be able to measure the results. And I need to see where I'm going to do that.